How soon after taking Toradol (ketorolac) can a patient restart aspirin (acetylsalicylic acid)?

Timing of Aspirin Resumption After Ketorolac (Toradol)

Aspirin can be safely restarted immediately after the last dose of ketorolac, as ketorolac's antiplatelet effects resolve within 24 hours of discontinuation, while aspirin should be resumed as soon as possible to minimize thrombotic risk in patients requiring antiplatelet therapy.

Pharmacologic Rationale

Ketorolac's Antiplatelet Duration

• Ketorolac causes reversible platelet inhibition that normalizes within 24 hours after stopping the medication 1
• Unlike aspirin's irreversible COX-1 acetylation, ketorolac's effects on platelet aggregation are temporary and resolve quickly once the drug is cleared 1
• The risk of bleeding complications with ketorolac is only slightly higher than opioids when used at appropriate doses and duration 2

Aspirin Resumption Urgency Based on Indication

For Secondary Prevention (High Thrombotic Risk):

• Restart aspirin immediately after ketorolac discontinuation without delay 3, 4
• Patients with recent coronary stents, stroke history, or acute coronary syndrome should have aspirin restarted within 24 hours maximum 3
• Delaying aspirin resumption increases mortality risk nearly 7-fold (HR 6.9) and results in 10 times higher mortality compared to continuing aspirin 4
• The median time to stent thrombosis is only 7 days when antiplatelet therapy is interrupted 5

For Moderate Risk (Stable Coronary Disease):

• Restart aspirin within 1-2 days after ketorolac cessation 3
• Ensure hemostasis is adequate before resumption 3

For Primary Prevention:

• Consider whether aspirin needs to be restarted at all, as bleeding risks may outweigh benefits 3, 4
• If restarted, timing is less critical and can occur within 1-3 days 3

Practical Algorithm

Step 1: Assess Thrombotic Risk

• High risk (recent stent <12 months, recent stroke, acute coronary syndrome): Restart aspirin immediately after last ketorolac dose 3, 4
• Moderate risk (stable CAD, remote cardiovascular history): Restart within 24-48 hours 3
• Low risk (primary prevention only): Consider if aspirin is still indicated; if yes, restart within 1-3 days 3, 4

Step 2: Assess Bleeding Status

• No active bleeding concerns: Proceed with immediate aspirin resumption based on thrombotic risk 3
• Minor bleeding concerns: May delay 24 hours while monitoring, but not longer in high-risk patients 3
• Active bleeding: Control bleeding first, but restart aspirin as soon as hemostasis achieved (typically within 24-48 hours maximum) 5, 3

Step 3: Special Considerations for DAPT

• If patient was on dual antiplatelet therapy, restart aspirin first (immediately to within 24 hours) 3
• Resume P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel) within 2-5 days maximum after hemostasis 5, 3
• Never discontinue both antiplatelet agents simultaneously due to extreme stent thrombosis risk 5

Critical Pitfalls to Avoid

Common Errors

• Do not wait 5-7 days to restart aspirin as is sometimes done with aspirin cessation before procedures—this prolonged delay is unnecessary after ketorolac and dangerous in high-risk patients 3, 4
• Do not assume ketorolac provides prolonged antiplatelet effects requiring extended aspirin-free periods—its effects resolve within 24 hours 1
• Do not treat all patients the same—thrombotic risk stratification is essential, as high-risk patients cannot tolerate even brief aspirin interruptions 3, 4

Contraindications to Immediate Resumption

• Active uncontrolled gastrointestinal bleeding 5, 3
• Intracranial hemorrhage 5
• Major surgical bleeding not yet controlled 3

Evidence Quality Considerations

The recommendation for immediate aspirin resumption is based on:

• Strong guideline evidence showing aspirin can be restarted immediately after procedures when hemostasis is achieved 3
• High-quality data demonstrating ketorolac's platelet effects normalize within 24 hours 1
• Robust evidence that aspirin delays increase mortality and thrombotic events in secondary prevention patients 4
• The 2024 ESC guidelines emphasizing early aspirin resumption (within 24 hours) for high-risk patients 5, 3

In practice, for most patients requiring aspirin for cardiovascular protection, restart aspirin the same day as the last ketorolac dose unless active bleeding is present.